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APPENDIX B: Title VI Complaint Form Erie County Department for the Aging Title VI and ADA Complaint Form Section I: Your Name: Complaint Type: ADA TITLE VI Address: Telephone (Home): Telephone (Work/Mobile): Email Address: Accessible Format Large Print Audio Tape Requirements? TDD Other Section II: Are you filing this complaint on your own behalf? Yes* No *If you answered "yes" to this question, go to Section III. If not, please supply the name and relationship of the person for whom you are complaining: Please explain why you have filed for a third party: Please confirm that you have obtained the permission of the Yes No aggrieved party if you are filing on behalf of a third party. Section III: I believe the discrimination I experienced was based on (check all that apply): ☐ Race ☐ Color ☐ National Origin ☐ Disability Date of Alleged Discrimination (Month, Day, Year): _____________ Agency name complaint is against: ______________________________________________ Location of where the alleged discrimination occurred:- _____________________________________ Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses. If more space is needed, please attach additional pages. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 87 | P a g e - E r i e C o u n t y G o i n g P l a c e s P o l i c y a n d P r o c e d u r e